The Transitional Care Clinic (TCC) program focus is on chronic disease management and readmission prevention for high-risk patients with heart failure (HF), chronic obstructive lung disease (COPD), and end stage renal disease (ESRD). TCC staff meet with inpatients at the bedside to provide chronic disease education, management, and care coordination for discharge and outpatient follow up. TCC staff work closely with multidisciplinary staff both inpatient and outpatient for optimal health management. Post discharge contact is provided through telephonic, video, and clinic follow-up. TCC staff evaluates and solve barriers around SDOHs identified. TCC Team includes RNs, NP, Pharmacist, CHW, SW, and Dietician.
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Job Type
Part-time
Career Level
Mid Level
Education Level
Associate degree